Rural midwifery

The conference organisers succeeded in getting some of the movers and shakers in maternity together in a very nice conference centre in Shrewsbury, for what turned out to be an encouraging and upbeat day.

Baroness Julia Cumberlege chaired the day capably with energy and enthusiasm, as you might expect; I was much pleased with her commitment to continuity of carer which she described as ‘a passion’ and emphasised repeatedly. She referred to the work of the National Perinatal Epidemiology Unit NPEU showing that 24% of premature births could be prevented by continuity of carer, and quoted Soo Downe: ‘if it was a drug you’d have to give it’.

Cathy Warwick set out ‘our vision’ of community hubs as one-stop shops with multiple facilities, including ultrasound, alongside centralised specialist care; Tracey Cooper, consultant midwife from Lanarkshire described ‘our experience’ of organising the services around the women and including antenatal care, dieticians, physiotherapy and much more at hubs, including an obstetric clinic once a week. Simon Wright, CEO Shrewsbury and Telford Hospital Trust (SaTH), introduced a slightly jarring note by focusing on the government’s targets of cutting the stillbirth rate by interventions during pregnancy,1 but also talked of efforts to increase births in MLUs.

Kathryn Gutteridge spoke of her work in setting up MLUs in the Birmingham area, where there had been a failing unit with high levels of intervention and low levels of recruitment. She started by listening carefully to experiences of service-users and learned lessons from hospices about their patient and family-centred approach, estimated that 30% of women need to give birth in hospital, the rest, as she has shown, can give birth outside with excellent outcomes, achieving the highest normal birth rate in the UK. She reminded us of the recent survey from Women’s Institute (WI) and NCT showing that 88% of women have not met their midwife before the birth. Adam Gornall, Clinical Director of SaTH, set out sustainable services in Shropshire talking of the need to encourage more use of the midwifery led units (MLU).

Women’s voices were heard too in presentations from service users, then lunch with ‘speed dating’ giving a good opportunity to meet and have a conversation with the speakers and other participants.

Cate Langley, Head of Midwifery in Powys, in a completely midwife-led service in a massive rural county with no obstetric unit, and 1200 births a year, told us how to deliver community based maternity services where the service staffs women not buildings, and Gill Walton, Director of Midwifery in Portsmouth gave us lessons from Portsmouth, where she has developed an app, ‘My Birthplace’ to support women’s choice of place of birth.

Childbirth activists have had difficulty mapping midwife-led units in the UK as there is considerable change and no central register so it was very useful to see some preliminary results from Denis Walsh, Associate Professor in Nottingham, who described the ongoing research into mapping and utilisation of midwifery units in England.2 A key finding is that there has been a significant increase of births in MLUs over the last 6 years following the
Birthplace study: he suggests that a conservative estimate of the proportion of women who could birth in MLUs, based on numbers booking midwife-led care in early pregnancy reduced by subsequent transfer to obstetric-led care, should be at least 30%.

Of course utilization of MLUs depends on their provision. Denis showed the large variation between trusts, some with no MLUs at all, but some with many. The closure of obstetric units with an increase in alongside provision but little overall increase in freestanding midwifery units (FMU) must mean many women travelling potentially avoidable distances in labour, however there has been a welcome drop in the number of trusts with no midwifery units at all.

There was agreement on the need to increase midwife-led care and much commitment to doing so, but the take home message for me was definitely the widespread acceptance of the importance of continuity of carer as well. This seems to me to be in stark contrast to the message in the minds of policy makers until recently (for example Midwifery 2000), which was that every woman needs a team and, at most, continuity of care. For me this is a very welcome and positive shift.